Written Policy and Best Practices It was somewhat difficult to find the policy for dressing changes, cap changes and site cultures for central vascular access devices. When asked, 81% of the RN’s were able to state how to get to the policy on the computer using MCN on their first try. Many thought it would be under central line dressing changes, but it is actually found by searching VAD. The policy was initially presented to nursing staff when first implemented. Education posters have been displayed periodically in break rooms through out the hospital and in-service demonstrations are utilized yearly at nursing skill workshops. The policy is evidence based and is supported by literature from the Joint Commission on Accreditation of Healthcare Organizations (JACHO). Central Line Dressing changes should be treated as a sterile procedure and preformed every 7 days or as needed for a compromised dressing ( Joint Commission, 2012). If drainage from the site is present during a dressing change, a culture should be initiated per hospital policy (2012). This portion is often not performed by the vast majority of nurses questioned. Written Policy and Best Practices It was somewhat difficult to find the policy for dressing changes, cap changes and site cultures for central vascular access devices. When asked, 81% of the RN’s were able to state how to get to the policy on the computer using MCN on their first try. Many thought it would be under central line dressing changes, but it is actually found by searching VAD. The policy was initially presented to nursing staff when first implemented. Education posters have been displayed periodically in break rooms through out the hospital and in-service demonstrations are utilized yearly at nursing skill workshops. The policy is evidence based and is supported by literature from the Joint Commission on Accreditation of Healthcare Organizations (JACHO). Central Line Dressing changes should be treated as a sterile procedure and preformed every 7 days or as needed for a compromised dressing ( Joint Commission, 2012). If drainage from the site is present during a dressing change, a culture should be initiated per hospital policy (2012). This portion is often not performed by the vast majority of nurses questioned. Observations vs. Best Practice *Only 83% of RNs on the floor were observed following proper policy procedure for central line dressing changes. *Most RNs followed procedure for changing dressings once a week but most often failed to do so when the dressing was compromised *Feeling rushed for time and forgetting were reasons given for why proper protocol was not followed along with varying interpretation of what constituted a “compromised dressing”. Deviation From Protocol If a fellow nurse is observed not following proper policy or procedure, it is the responsibility of the witness to report to management what is observed. One may approach a fellow nurse to help them understand what proper policy is and where to locate it. (Finkleman, 2012).Management must be informed if continued deviance is observed. Deviation From Protocol If a fellow nurse is observed not following proper policy or procedure, it is the responsibility of the witness to report to management what is observed. One may approach a fellow nurse to help them understand what proper policy is and where to locate it. (Finkleman, 2012).Management must be informed if continued deviance is observed. References Finkleman, A.(2012).Leadership And Management for Nurses: Core Competencies for Quality Care. The Joint Commission. Preventing Central Line– Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May References Finkleman, A.(2012).Leadership And Management for Nurses: Core Competencies for Quality Care. The Joint Commission. Preventing Central Line– Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May